The National Consumer Protection Technical Resource Center: The Center of Service & Information for SMPs

Health Care Fraud

Medicare Fraud

Here are examples of Medicare fraud:

  • Billing for services or supplies that were not provided
  • Altering claim forms to obtain a higher payment amount
  • Billing twice for the same service or item
  • Billing separately for services that should be included in a single service fee
  • Misrepresenting the diagnosis to justify payment
  • Continuing to bill for services or items no longer medically necessary
  • Billing for rental equipment after date of return
  • Billing “non-covered” services or items as “covered” services
  • Ordering unnecessary lab tests
  • Refusing to bill Medicare for covered services or items
  • Using another person's Medicare card to obtain medical care
  • Soliciting, offering, or receiving a kickback, bribe, or rebate (for example, paying for referrals of patients)
  • Completing a Certificate of Medical Necessity (CMN) for a patient not professionally known by the provider
  • Completing a CMN when not authorized (for example, a supplier completing a CMN for the physician)
  • Signing authorizations for medical equipment or procedures that are not medically necessary
  • Waiving co-insurance or deductible
  • Billing for home health care services for patients who do not meet the requirement of “homebound” status
  • Using unethical or unfair marketing strategies, such as offering beneficiaries free groceries or transportation to switch providers
  • Billing social activities as psychotherapy
  • Billing group services as individual services for each patient in the group
  • Repeatedly violating the participation agreement, assignment agreement, or limiting charge
  • Outpatient hospital services provided within 72 hours of surgery or other inpatient procedure (known as “the 72-hour rule”)
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